Licence Appeal Tribunal File Number: 24-007247/AABS
In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.
Between:
Jayden Tranter
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
VICE-CHAIR:
Neil Levine
APPEARANCES:
For the Applicant:
Sherilyn Pickering, Counsel
For the Respondent:
Jonathon Kahane-Rapport, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Jayden Tranter, the applicant, was involved in an automobile accident on February 28, 2006, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Accidents on or after November 1, 1996 (the “Schedule”). The applicant was denied benefits by the respondent, Co-operators General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUES
2Is the applicant barred from proceeding to a hearing for all of the benefits claimed in this application?
SUBSTANTIVE ISSUES
3The substantive issues in dispute are:
i. Is the applicant entitled to $2,200.00 for psychological assessment, proposed by Fox Psychological Services in an OCF-18/treatment plan (“plan”) dated September 21, 2022?
ii. Is the applicant entitled to $1,825.93 for occupational therapy in-home assessment, proposed by Entwistle Power Ahmad Occupational Therapy Corporation in a plan dated June 14, 2022?
iii. Is the applicant entitled to $3,100.00 for psychology assessment, proposed by Dr. Jeremy Frank in a plan dated August 23, 2022?
iv. Is the applicant entitled to $4,309.72 for occupational therapy services, proposed by Entwistle Power Ahmad Occupational Therapy Corporation in a plan dated July 18, 2022?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULTS
4I find that:
i. The applicant is not barred from proceeding to a hearing for the substantive issues.
ii. The applicant is not entitled to $2,200.00 for psychological assessment.
iii. The applicant is not entitled to $1,825.93 for occupational therapy in-home assessment.
iv. The applicant is not entitled to $3,100.00 for psychology assessment.
v. The applicant is not entitled to $4,309.72 for occupational therapy services
vi. The applicant is not entitled to an award.
vii. The applicant is not entitled to interest.
PRELIMINARY ISSUE ANALYSIS
5The Case Conference Report and Order of October 28, 2024 does not state on what statutory basis the respondent is seeking that the applicant be barred from proceeding to a hearing.
6Further, the respondent does not indicate in its submissions what the basis is for its argument that the applicant should be statute-barred. Rather, it argues that due to the passage of time, the benefits in dispute are not reasonable and necessary, and the applicant does not have entitlement under the Schedule for the benefits in dispute.
7Given that the respondent has not identified the basis for the preliminary issue as set out in the CCRO, I decline to find that the applicant is statute-barred, and therefore this dispute may proceed to a hearing.
ANALYSIS
Background
8The applicant was a pedestrian and was struck by a school bus on February 28, 2006. She was six years old at the time.
9The applicant was treated for the injuries caused by the accident and provided with benefits by the respondent. On November 16, 2006, the respondent closed the file because there was no response to messages left for the parents of the applicant (who were at the time the legal guardians of the applicant). No expenses, treatment plans, notices or communications were received by the respondent from November 16, 2006 to September, 2021.
10On June 13, 2022, a new OCF-1 was submitted to the insurer. A new OCF-18 for attendant care benefits was submitted on June 24, 2022 (dated May 19, 2022). This OCF-18 was denied, and the applicant in its submissions withdrew this treatment plan for attendant care benefits.
Legal Test for Treatment Plans and Services
11For accidents on or after November 1, 1996 until March 1, 2006, Part V of O. Reg. 403/96, s. 14 states that the insurer shall pay an insured person who sustains an impairment as a result of an accident a medical benefit. The medical benefit shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of the accident and lists the services and treatments which are eligible.
12Therefore, the question is whether the treatment plans and services claimed are reasonable and necessary as a result of the accident.
Psychological assessments from Dr. Jeremy Frank ($3,100.00) and Dr. Philip Miller ($2,200.00)
13The applicant is not entitled to these psychological assessments.
14The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
15The goals of the assessment by Dr. Frank, a psychologist are to document and assess the applicant’s mixed anxiety and depressive disorder and to formulate a treatment plan. The goals of the assessment by Dr. Miller, a psychologist are to identify the nature and extent of the applicant’s psychological impairments in order to determine a course of treatment.
16There is considerable overlap and duplication in these plans. Both plans propose an assessment, evaluation and/or testing of the applicant.
17The applicant submits that these plans are necessary and reasonable because the psychological issues they are addressing are the result of the subject accident. The applicant submits clinical notes and records from February 7, 2011 which note that the applicant had panic attacks twice and sleep impairment on a few occasions. Her pediatrician, Dr. Cheryl Clayton, diagnosed anxiety and panic attacks and recommended counselling. On January 16, 2012, she again visited Dr. Clayton complaining of ongoing anxiety and sleep impairments. She was prescribed cognitive behavioural therapy.
18The applicant submits that any mental health impairments began immediately after the MVA, but this is only corroborated in a psychovocational assessment dated November 4, 2024, more than 18 years after the accident. This assessment does not link her psychological issues to the accident but rather notes that according to her mother, the applicant’s anxiety, sleep issues and other problems began post-accident, but there are no psychological or medical CNRs to corroborate this.
19I reject the respondent’s argument that because no expenses, communication or forms were submitted to them, the claim is therefore closed.
20However, there is no medical evidence that associate the applicant’s psychological issues with the subject accident. I also note that that the subject accident was in 2006, five years prior to her first visit to her pediatrician about any psychological issues, and immediately post-accident there is no documentation of any psychological distress or impairments. In my view, the significant gap in time, and the lack of medical evidence connecting the applicant’s psychological issues with the accident support a finding that the applicant has not established that she has an accident-related psychological condition that warrants further investigation by way of assessments.
21On a balance of probabilities and based on the evidence before me, I find that these assessment and treatment plans are not reasonable or necessary.
Occupational therapy assessment and occupational therapy services ($1,825.93)
22I find that the occupational therapy assessment and occupational therapy treatment plans are not reasonable or necessary.
23The applicant submits that the OT in-home assessment and services goals were to determine the applicant’s level of participation with daily activities pre- and post-accident, assess physical, psychosocial and cognitive functions post-accident related to self care productivity and leisure, identify equipment and supports, identify barriers preventing a return to activities and identify OT-specific goals related to function.
24It was not made clear by the applicant nor the treatment provider how it is possible to assess pre-accident activities when the applicant was six years old at the time of the accident and the accident occurred almost 16 years before the proposed treatment plan.
25The applicant submits CNRs from her family doctor that note her hip issues and pain related to the accident from 2006. However, there are no clinical notes and records from any other medical professionals to link these issues to her accident 16 years prior to the submission of the 2022 OCF-1. In fact, CNRs from Dr. Clayton, the applicant’s family doctor, about a December 14, 2009 x-ray of the applicant’s hip and left femur conclude that there were no sequelae from the previous pelvic fracture. And CNRs from Dr. Clayton from February 7, 2011 note panic attacks, nausea, shaking, dizziness and other symptoms but do not relate them to the subject accident.
26The respondent has submitted that the applicant could not require occupational therapy services or an assessment given that for more than 20 years post-accident she danced competitively and taught dance, and was therefore physically active. This was evidenced by social media and news articles where the applicant is seen dancing and working as a dance instructor. She was in the Arts Nipissing program majoring in dance. There are also few mentions in medical records relating any reported impairments, psychosocial or cognitive issues to the subject accident. Based on these activities, I am therefore unable to conclude the applicant suffered continuing pain or physical issues as a result of the accident.
27It is for these reasons that, on a balance of probabilities, I find these treatment plans and assessments for occupational therapy are not reasonable or necessary.
Occupational therapy services ($4,309.72)
28The applicant is not entitled to this treatment plan.
29This treatment plan is for pain management of the applicant’s hip and head pain and for sleep hygiene. Its goals are to increase the applicant’s cognitive abilities, including planning, memory and concentration as the applicant client has difficulty paying attention to tasks, and to decrease the applicant’s emotional symptoms, which cause difficulty with motivation.
30There has been no evidence presented to relate these psychological issues (pain, sleep, planning, memory, concentration, motivation) to the subject motor vehicle accident in 2006. While the applicant has a documented history of psychological problems and issues, there are no notes or records from a medical professional that relate them directly to the subject accident.
31Accordingly, I do not find these additional OT services to be reasonable and necessary.
Interest
32Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
33There are no overdue benefits payable and therefore no interest applies.
Award
34The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
35The applicant did not provide or lead any evidence to show that the respondent withheld or delayed benefits in an excessive imprudent, stubborn, inflexible, unyielding or immoderate manner. On the contrary, the respondent made attempts following the accident in 2006 to contact the applicant, offer services and enquire about progress. The applicant did not contact the respondent from 2007 through 2020. When this claim recommenced on June 13, 2022, there is no evidence that shows the respondent did not adjust the file in a timely, efficient and professional manner.
36Therefore, I conclude that the applicant is not entitled to an award.
ORDER
37I order that the applicant:
i. Is not entitled to the treatment plans and assessments claimed.
ii. Is not entitled to interest.
iii. Is not entitled to an award.
Released: March 25, 2026
__________________________
Neil Levine
Vice-Chair